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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />5/1 /17 <br />Matt Chlebowski <br />Purchasing ® George King <br />Department Central Services <br />U <br />Agreement <br />® Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Change Order No. <br />❑ <br />CIO & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ <br />Traffic Control <br />(� <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBEANBE Contractor <br />MBENVBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Clean Fuels Ohio would like us to test drive an electric vehicle <br />through the demonstration project "Midwest DRIVES Initiative" for <br />10 days and give them our opinion. <br />Lj Yes U No Lj If Yes, Approved by Purchasing <br />n MBE M WBE <br />❑ No ❑ Yes Name of Com an <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Vehfv, Iran. etc. <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Copy <br />Original <br />❑ <br />❑ <br />Dispersal After Approval <br />Matt Chlebowski & Sheila Enos <br />